Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who is 1 hour postpartum and observes a large amount of lochia rubra and several small clots on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?
A. Document the findings and continue to monitor the client.
The findings described are within the expected range for 1 hour postpartum, as lochia rubra and small clots are normal during the early postpartum period. The firm, midline fundus suggests adequate uterine contraction. Documenting the findings and continuing to monitor the client's progress are appropriate.
B. Increase the frequency of fundal massage.
Increasing the frequency of fundal massage is not necessary as the fundus is already firm and midline.
C. Encourage the client to empty her bladder.
Encouraging the client to empty her bladder is important for uterine involution, but it is not the priority in this scenario, as the fundus is already firm and midline.
D. Notify the client's provider.
Notifying the client's provider is not necessary at this time, as the findings are within theexpected range for the early postpartum period and do not indicate any immediate complications.
This question is an excerpt from Nurse Dive's nursing test bank - Ati N230 Exam 3 With Ngn Maternal Newborn Proctored Exam. Take the full exam now
Full Explanation
A. The findings described are within the expected range for 1 hour postpartum, as lochia rubra and small clots are normal during the early postpartum period. The firm, midline fundus suggests adequate uterine contraction. Documenting the findings and continuing to monitor the client's progress are appropriate.
B. Increasing the frequency of fundal massage is not necessary as the fundus is already firm and midline.
C. Encouraging the client to empty her bladder is important for uterine involution, but it is not the priority in this scenario, as the fundus is already firm and midline.
D. Notifying the client's provider is not necessary at this time, as the findings are within the expected range for the early postpartum period and do not indicate any immediate complications.
Similar Questions
A nurse is caring for a client who is 3 days postpartum and is attempting to breastfeed. Which of the following findings indicate mastitis?
A. A white patch on a nipple
A white patch on a nipple may indicate a fungal infection such as thrush but is not typically associated with mastitis.
B. Cracked and bleeding nipples
Cracked and bleeding nipples are common in breastfeeding but are not specific to mastitis.
C. Swelling in both breasts
Swelling in both breasts can occur with engorgement but is not indicative of mastitis, which typically presents with localized symptoms.
D. Red and painful area in one breast
A red and painful area in one breast is a classic sign of mastitis. Mastitis is an infection of the breast tissue that often presents with localized redness, warmth, swelling, and pain in one breast. Other symptoms may include fever, chills, and flu-like symptoms.
Full Explanation
A. A white patch on a nipple may indicate a fungal infection such as thrush but is not typically associated with mastitis.
B. Cracked and bleeding nipples are common in breastfeeding but are not specific to mastitis.
C. Swelling in both breasts can occur with engorgement but is not indicative of mastitis, which typically presents with localized symptoms.
D. A red and painful area in one breast is a classic sign of mastitis. Mastitis is an infection of the breast tissue that often presents with localized redness, warmth, swelling, and pain in one breast. Other symptoms may include fever, chills, and flu-like symptoms.
A home health nurse is teaching a client who is breastfeeding about managing breast engorgement. Which of the following client statements indicates understanding of the teaching?
A. "I'll feed my baby every 2 hours."
Feeding the baby every 2 hours helps to ensure frequent emptying of the breasts, which can help alleviate engorgement by reducing milk stasis and promoting milk production regulation.
B. "I'll apply cold compresses 20 minutes before each feeding."
Applying cold compresses before feeding may temporarily reduce discomfort but does not address the underlying cause of engorgement or promote milk removal.
C. "I'll try drinking an herbal tea to reduce the engorgement."
Drinking herbal tea is not proven to effectively reduce breast engorgement, and it is important for the client to focus on frequent breastfeeding or pumping to alleviate engorgement.
D. "I'll let my baby drain one breast at each feeding."
Allowing the baby to drain one breast at each feeding may lead to uneven milk production and exacerbate engorgement. It is important for the client to offer both breasts at each feeding toensure adequate milk removal from both breasts.
Full Explanation
Feeding the baby every 2 hours helps to ensure frequent emptying of the breasts, which can help alleviate engorgement by reducing milk stasis and promoting milk production regulation.
Applying cold compresses before feeding may temporarily reduce discomfort but does not address the underlying cause of engorgement or promote milk removal.
Drinking herbal tea is not proven to effectively reduce breast engorgement, and it is important for the client to focus on frequent breastfeeding or pumping to alleviate engorgement.
Allowing the baby to drain one breast at each feeding may lead to uneven milk production and exacerbate engorgement. It is important for the client to offer both breasts at each feeding to ensure adequate milk removal from both breasts.
A nurse is caring for a client who is 2 hours postpartum following a vaginal birth. Which of the following findings indicates the client's bladder is distended?
A. Fundus palpable to right of midline
The fundus palpable to the right of midline suggests that the bladder is distended and pushing the uterus to the right, displacing it from its expected midline position.
B. Less than 2.5 cm of rubra lochia on perineal pad
Less than 2.5 cm of rubra lochia on the perineal pad is a normal amount of lochia for 2 hours postpartum and does not necessarily indicate bladder distention.
C. Client report of frequent uterine contractions
Client report of frequent uterine contractions may indicate uterine involution but does not directly assess bladder distention.
D. Client report of increased thirst
Client report of increased thirst may indicate dehydration but does not directly assess bladder distention.
Full Explanation
A. The fundus palpable to the right of midline suggests that the bladder is distended and pushing the uterus to the right, displacing it from its expected midline position.
B. Less than 2.5 cm of rubra lochia on the perineal pad is a normal amount of lochia for 2 hours postpartum and does not necessarily indicate bladder distention.
C. Client report of frequent uterine contractions may indicate uterine involution but does not directly assess bladder distention.
D. Client report of increased thirst may indicate dehydration but does not directly assess bladder distention.